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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850486
Report Date: 04/09/2024
Date Signed: 04/09/2024 10:49:15 AM

Document Has Been Signed on 04/09/2024 10:49 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRALIZED APP UNIT, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:WALNUT GARDEN IVFACILITY NUMBER:
195850486
ADMINISTRATOR/
DIRECTOR:		ILLOUZ, IZHAKFACILITY TYPE:
740
ADDRESS:5128 CEDROS AVETELEPHONE:
(818) 855-1459
CITY:SHERMAN OAKSSTATE: CAZIP CODE:
91403
CAPACITY: 6CENSUS: 6DATE:
04/09/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Licensee/administrator Izhak IllouzTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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Facility Type: RCFE
Application Type: CHOW
Capacity: 6
Census (if any clients in care): 6
COMP II Participants: Licensee/administrator Izhak Illouz
Interview Method: Telephone interview

On 04/09/2024 applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Starla Currin
LICENSING EVALUATOR SIGNATURE: DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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